Welcome to the University of Michigan Dentistry
Podcast Series promoting oral health care worldwide. Today we’re going to talk about the facial
mask which is an orthopedic device developed by Professor Henri Petit of Baylor Dental
College in Dallas, Texas. This particular plants is a new version of a relatively old
type of orthopedic approach to correcting the problems of children who have an imbalance
between the size of their upper jaw and the size of their lower jaw. We’re going to be
dealing today with this particular type of facial mask of plants and I’d like to go through
the various procedures with a real life patient and a real life father who will be getting
— the patient will be getting this facial mask for the first time today. How are you,
Stacey? Stacey: Fine.
Dr. McNamara: Good. You’re beginning to lose a little bit of your shyness, right? Okay.
Now what we’re going to be doing today is to deliver the facial mask but this, in fact,
is the second stage of her overall treatment. Now you remember when we first talked in the
initial exam and the consultation that Stacey has a rather significant problem with regard
to her upper jaw and her lower jaw. You remember that don’t you?
Father: Oh yeah. Dr. McNamara: Now she was sent to me by her
pedodontist and I’d like to go over again the problems that she had. This is the initial
facial photograph that was taken at the time of the records appointment. And in the facial
photograph you can see very clearly that there is for a girl of her age which is today seven
years of age, a relative mandibular prognathism and under development of the upper jaw giving
her a somewhat prognathic facial appearance. This is also seen in the front view as well. If you look at the lateral head film, you
can also see the underdevelopment of the maxilla and the slight amount of mandibular prognathism
evident in this film as well. Now because of this she has developed a class III malocclusion
in which the lower teeth are biting in front of the upper teeth. Now one further problem
that we have is that she does not have any first permanent molars erupted and the reason
for that of course is because of her age so she’s slightly delayed in her dental development
and she is also missing a first primary molar which has been restored with, or has been
maintained with a space maintainer which you can just see the outline on in the dental
cast. Now I made the decision because of her age, because she’s getting fairly close to
eight and it looked like there was a little bit of time left before the first molars were
to come in to use a bonded expander on her dental arch which would only incorporate the
primary teeth and not incorporate the first molars. If I had my choice, I would much prefer
to have the first molars in place because it gives it a much better anchor unit. Now
the appliance that we used and you’ll remember the last time you were in the office we put
in a bonded rapid palatal expander which is very similar to this demonstration model here.
Do you recognize that? Stacey: Yes.
Dr. McNamara: What this is, is a wire framework that goes around the outside of the teeth
and there’s a jack screw in the middle which is expanded as you know one crank per day.
So that for the day that this is cemented and usually for the next month, you or Mom
or someone will go in and I’ll use this pen as an example of a key that goes in here.
And you can see that this would be cranked one-quarter turn everyday and when this is
taken out the key should be in the back of the mouth. The key of course is only about
an inch long so it doesn’t stick her in the throat. Now to this particular type of expander
is attached these hooks and this is what we’re going to be using today, these facial mask
hooks, which will take the elastic, we’re going to use rubber bands and take the elastic
and run this from the bonded appliance to the facial mask which we saw two examples
of a little bit earlier. Now I figure we’d be of interest to find out
how things have gone during the first two weeks when she’s had the expander in place.
Have you had any pain or any trouble with your expander?
Stacey: No. Dr. McNamara: Nothing at all.
Father: I thought you said the two places where the rubber bands fasten onto was hurting
your gums. Didn’t you say they were hurting your gums?
Dr. McNamara: Just a little bit. Is it okay now? Okay. Well we’ll check that when we check
your teeth. Now we put this expander in two weeks ago and you’ve had your dad crank or
your mom crank this every night, right? Have you felt any tingling sensation in your nose
at all? Stacey: Yes.
Dr. McNamara: Is it painful, does it hurt? Stacey: No.
Dr. McNamara: Okay that’s good. Have you had any trouble as far as expanding the appliance?
Father: No, no, not just a little bit. Not much.
Dr. McNamara: Was that mostly in finding the hole?
Father: Just in finding the hole. You know, you have to get it turned toward the light
just right. And so you can see it. Dr. McNamara: Alright. Okay Stacey I’d like
to use a mirror and see if we can get a view of your teeth with the expander in place,
okay? Will you hold this for me for a minute? Okay tip your head back, open real wide. Now
looking in the mirror we see a view of the palate. In this case the teeth that are involved
are the cuspid, the first deciduous molar and the second deciduous molar. On the one
side where the deciducous molar is not present we filled that area in with acrylic because
this appliance will be on somewhere between six and 12 months depending upon the speed
of treatment. In the fellow view, we can see that her teeth are still in an anterior crossbite
position particularly on the right side. There’s a one or two millimeter midline diastema between
her upper central incisors which again is very common in a rapid palatal expansion type
of appliance. We can also see from the front the two hooks to which we’re going to attach
the elastics. In profile view, the anterior crossbite is
still evident although we’re getting closer to an end-to-end relationship. Can you move
your jaw any further back than you are now? I think that’s just about it, okay.
Now this is in contrast of course to what we see in the original models. You see there’s
no space between the upper central incisors and the teeth were not nearly as far forward,
the upper teeth are not as far forward as they are now.
Now the facial mask comes in two sizes. There’s a standard size and then there’s a small size.
Okay? Now, I’m going to try each of these on you if you hold that for me please.
Father: Okay. Dr. McNamara: Now I think immediately it will
become clear that the standard size is too big because as soon as we do this we put a
hole in her chest. Because of this thing here so that is obviously not the right size. This
is too long. And what we’ll find is that the smaller sizeů Let me sit you up just a little
bit okay. And we’ll sit you up there a little bit too. Okay. Now we can see that the smaller
size is going to be fitting her perfectly correctly and for the most part these things
are very easily given to the patient. There’s only one adjustment that you have to make.
Now we can see that the upper part should lie right on her forehead and this lower part
which is lined with a kind of a foam material and this can also be supplemented with Kleenex
or moleskin or anything of that sort as she wears this stuff starts to wear out. This
should fit quite comfortably on her chin. Father: That appliance now, is that going
to develop a rash or skin irritation of any kind?
Dr. McNamara: If a patient wears this on a 20-hour a day basis, particularly if they’ve
worn it for a long period of time, there’s very often a redness when it comes off for
five or ten minutes. There are some patients who do develop a rash of some sort and then
we use a cortisone cream or just lining it with Kleenex or something of that sort and
that seems to work out quite nicely. Father: Is there any way of cleaningů?
Dr. McNamara: You can wash it off but it’s almost better to just place this lining with
moleskin or something of that sort. Father: Okay.
Dr. McNamara: Now what we need to do is first of all determine whether this crossbow part
is in the proper orientation and the way this is done, and if you can turn toward me a little
bit, thank you. We should be able to see the elastics and we’re going to useů These are
5/16th inch 14 ounce elastics so they are very strong. We’re going to take one of these.
You want to hold this here for me? Well I’ll tell you what we’ll just take it off and put
it down here for right now. We’re going to take one of these elastics
as you can see here I think background on my hand. And we’re going to take this, close
down about half way and we’re going to hook it on the hook, okay? Then we’re going to
do the same thing with another elastic and you can do this just as easily with your fingers
as I can with this. And then we’re going to take the facial mask and we will soon find
out whether or not this is in the right position. You should put your finger pressure on the
facial mask. Like so. And actually, now close your lips
please. Now you see this is riding a little bit too high. See how this is riding high
in here? Father: Uh-huh.
Dr. McNamara: So what I have to do then is I have to go in and loosen up, okay bite down
please. Okay I’ve got to loosen the Allen screw that holds this on and drop it down
maybe a quarter of an inch. Father: Okay now will that have to be adjusted
again orů? Will it stay? Dr. McNamara: It should stay.
Father: There. Dr. McNamara: Okay we’re going to take an
Allen wrench. Put it in here. And drop this down. Then we’re going to screw it up tightly. It’s
very important that this remain tight because there’s a tremendous amount of force on the
elastics. Then we’re going to put this thing back in place like we saw before. Close down a little bit. There we go. Take
this. Now we’re going to take it like that. Now that’s pretty good. I might just drop
this down just a little bit more. Now I guess that’s pretty good. The main thing that we
want to avoid here is to have irritation of this on the lip because anything that causes
discomfort to your daughter is going to make her not want to wear it.
Father: Right. Dr. McNamara: And it’s the full-time wear
with a young lady that has as severe a problem as she has is extremely important so we do
that. So you understand we hold this down with one hand and then place these in position
with the other, okay? Father: Now will they break?
Dr. McNamara: Not very often these elastics are very strong. If they break, just like
any rubber band, they will come back and pick her off on the lip a little bit so when you
put it on and you take it off there’s no reason why she couldn’t do it herself after she learns
how to do it. You should be very careful to hold these very firmly with your fingers as
I have done. Father: Okay.
Dr. McNamara: I want to talk now about the instructions for the appliance wear. First
of all I want you to continue to expand her for about eight more times. One crank per
night. Father: Okay.
Dr. McNamara: And that should get the upper jaw up in the right position relative to the
lower jaw. Remember we also have to make sure that we not only get it in the right position
the way it is now but we also have to expect that it’s going to be moving forward and so
when we need slightly less expansion as we move forward rather than if we just left it
in the position that it is here. Secondly, I want you to listen to this for me okay?
I want you to wear this all the time and you don’t have to wear this full-time today because
I want you to break as you wear it for the next week or so I want you to wear it more
and more time. Does it feel real tight now? No? Does it not too bad? Because I would expect
with all the force in there that that would feel really tight. It could very well be that
the suture system that holds the upper jaw in place has been somewhat disrupted by the
expansion and therefore we might be able to see some relatively quick movement as I would
expect. Usually we see within a month a very substantial change in the position of the
upper jaw relative to the lower jaw. Father: Good.
Dr. McNamara: Now do you have any questions about this procedure?
Father: You remember asking me about wrestling with Steven, your little brother? She was
concerned that he might break the appliance or it might hurt her.
Dr. McNamara: That’s a real good point. When you have this on, and I can’t stress this
enough, you probably would do more damage to somebody else than she would to herself
because these things that are sticking out here could certainly poke somebody very nicely.
So that whenever you have this on, I don’t want you to be wrestling with your brother
or anybody else, okay? And you have to be real careful. If she’s out really horsing
around somewhere I would have her take it off. But basically we want to get 20 hours
a day. That gives her four hours to eat and to do the others things that she might have.
Father: You want her to wear this when she sleeps?
Dr. McNamara: Yeah. When she sleeps as well. Father: Just take if off when, it would pretty
hard to eat with that on. Dr. McNamara: Right. Although, you’ll find
that some kids are really ingenious and they don’t have to go through all the problems
of getting it on and off and they’ll be able toŚcan you open your mouth for me? See? She
can get food in there very easily. Okay we’re going to look at you again and see how much
improvement that you’ve made so you make sure you wear it for me, okay? Thank you. Today is June 25th and it’s been about four
and a half weeks since Stacey began wearing her facial mask. How you doing today?
Stacey: Fine. Dr. McNamara: Okay. How have you been? Have
you been wearing the mask like we told you? Stacey: Yeah.
Dr. McNamara: Okay I want to talk to your dad for a minute about the actual sequence
of how you’ve been wearing it. How’s it been going?
Father: Well, I really don’t think she’s wearing the appliance as much as she’s supposed to.
She’ll take it off to eat. If I don’t watch her, she won’t put it on right away and sometimes
she’ll say going in the swimming pool or brushing her teeth for an excuse and if I don’t keep
an eye on her she won’t have it back on right away.
Dr. McNamara: So what you’re saying is it’s not the easiest thing in the world to wear
one of these types of face masks. Father: Right.
Dr. McNamara: How many hours a day do you think she’s actually getting in?
Father: Well she’s probably getting in a good 20 hours a day.
Dr. McNamara: Okay, in fact then, if she’s getting in 20 hours a day that’s not so bad
at all. I think especially during the summer time when kids are out playing and so on to
get 20 hours a day is actually pretty decent so I have no real complaints about that. How’s
it been for you to wear? Stacey: Fine.
Dr. McNamara: Has it been okay? Now I can see and I’ll take off your mask in a minute
that this lower part down here, it looks a little different than when we saw it last
time, is that right? Do you have any soreness down in this area?
Stacey: No. Dr. McNamara: No. How about redness?
Stacey: No. Dr. McNamara: Has she complained at all?
Father: No the only thing she’s complained about is just the chin cup is deteriorated
from being wet and sweating, just from wearing it. That’s the only thing she’s really complained
about. She hasn’t complained about it being uncomfortable or anything like that.
Dr. McNamara: How about rough housing with her brother, she has a brother right?
Father: Right, she has a younger brother. Dr. McNamara: Any problems with that?
Father: No, you haven’t had any problems, have you? With Steven?
Stacey: No. Father: You haven’t banged him, have you?
Stacey: No. Dr. McNamara: Okay well first of all you can
see that the mask itself is fitting pretty well. I still think there perhaps this might
still be a little bit too high and we’ll adjust that after we get done here. But basically
I think the mask fits real nicely. Are you comfortable with that like it is there? Now will you take it off for me? Father: Usually she just rips it right off.
Dr. McNamara: Yeah I think the rubber band was twisted. Okay, now if we can get a close-up
here of the mask. You can see what the mask looks like after it’s been worn for about
four or five weeks. Now this is just tape, isn’t? Some kind of medical tape?
Father: That’s uhů mohair? Dr. McNamara: Oh moleskin that’s taped in.
Father: Moleskin. That’s moleskin on there. And it looks like she’s put some tape on it
since I’ve put that on. Dr. McNamara: I think that looks pretty decent.
Now if we can get a close-up of her chin. Bite down please. You can see just a little
bit of redness in there which is typical of facial mask patients. Well, this morning just
before you came to the TV studio, you went to my office and got an X-ray taken, remember? And I wanted to see in the one month period
of time whether or not there’s been any change in her bite. This is the X-ray that was taken
on March 15th which was basically two months before the visit here to the television studio
the first time. And in this case you can see a class I to a class III type of malocclusion
with an anterior crossbite so that the lower teeth were biting in front of the upper teeth.
This is the film that was taken this morning. And you’ll notice that there’s been a rather
dramatic change in both the anterior and posterior position of the upper and lower jaw and also
you’ll notice that there’s been an increase in lower anterior facial height. Now the reason
for that is because the thickness of the appliance has caused some downward and backward rotation
of the lower jaw and also we’re seeing according to the tracings some forward movement of the
upper jaw as well. This is the occlusion that Stacey has today. And you’ll notice there’s
an increase in the amount of overjet so that it is not a negative overjet like it was previously.
That means basically her upper teeth are more further forward than they were the last time
that I saw her a month ago. This is in contrast to the occlusion shown
here which is taken from the first video tape which shows her occlusion as it was after
the expander had been placed but before the facial mask was being used.
Here’s the view from the side. You’ll notice that the cuspid relationship is more toward
class I and that there’s a positive overjet in the anterior area. This once again is compared
to the pre-treatment overjet taken at the last session. Alright Stacey, I’d like you to put this back
on for me now. Can you do it without a mirror? Father: Uh-huh. Dr. McNamara: Here’s another rubber band. She’s a little more adept at this than when
we saw her last time. Father: Oh yeah, she can whip that thing on
and off like there’s nothing to it. Dr. McNamara: Okay now once again we’ll drop
this down a little bit. Now I think that looks fairly decent. Just a minute, let me drop
this down one more time. Okay, I think that pretty well does it for
today. I’d like to see you again in about two months. And we’ll see how much more progress
you make. Any comments or suggestions that you might have? What’s it been like to be
the dad of somebody wearing this? Has it been hard or not? Father: No not at all. She does everything
she normally does with the exception of eating. She has to take it off when she eats and when
she goes in the pool. Dr. McNamara: Sounds good. See you in two
months, okay? It’s been three and a half or four months
now since Stacey has received the facial mask and she’s back today. We’re going to take
a look and see how things are going and then talk to the dad and see if we can make some
small adjustments that are necessary on the appliance. How are you today?
Stacey: Fine. Dr. McNamara: Okay, now have you been wearing
the appliance as I’ve asked you? Stacey: Yeah.
Dr. McNamara: How has she been doing in that respect since the last time you were here?
Father: She’s doing pretty good. She’s been real pleased with the way she’s wearing it.
Dr. McNamara: Has she been getting in the 20 hours or so a day that I’ve asked?
Father: Yes, she’s been doing real good. Dr. McNamara: Have you found that it is easier
to get her to wear it during not the summer time but during the school year. Is this an
easier time than during the summer? Father: Yeah, I think so because she’s so
busy playing in the summer time that she’s always looking for an excuse to take it off. Dr. McNamara: Okay. Now Stacey I want you
to let me take a look at the mask. I see a number of things that I perhaps would
like to adjust after the appliance has been worn for some period of time. First of all
the upper pad is resting a little bit high on her forehead and that’s been a problem
that I have mentioned I think in the earlier recording sessions. We also find that the
lower pad in here which in fact has been replaced since the last time we were in the television
studio, looks like its digging in a little bit underneath her lip although it is not
causing a particular problem inside her mouth. The crossbar maybe in fact riding a little
bit higher than it should because the elastics as we can see here are still pulling up her
lip slightly. Now would you take that off for me please? Only on television does she have problems
like this, right? Father: Uh-huh. Dr. McNamara: Okay. Now we can see once again
in this particular case that she still has some area of wear in the pad region and I
think this is something that in future models we’re going to have to be perhaps concerned
with. Now looking intraorally we can see that there
is now a positive overbite and overjet relationship established. I would estimate that the upper
teeth are perhaps two to three millimeters, the upper anterior teeth, are two to three
millimeters ahead of the lower teeth. I might also note that Stacey had a frenectomy carried
out in the lower arch about a month ago because we were concerned about the pull of the attached
gingiva by the frenum and I don’t think this has anything to do with the facial mask therapy.
Now we can look at her bite in the front view and now compare it to the original intraoral
view taken at the time of the first recording session. In profile view we can see the sagittal jaw
relationship and we notice that the upper teeth are perhaps now even three to four millimeters
ahead of the lower anteriors. We also notice that the cuspid relationship is now class
I maybe even a little bit toward class II. This is in comparison in the footage taken
on the day of the first recording session. Now I’ve had Stacey put the facial mask back
on and I want to address a couple of questions. First of all, we see here that this lower
pad is digging in underneath the lower anterior region. I found recently that one of the ways
of correcting that is to actually make an additional bend in this face bow that comes
down the center of her face. Now I want you to take that off for me, okay? Now one of the things we discussed on an earlier
tape is the fact that this face bow or this center support bar comes in two different
sizes, a small size and a standard size. Now just recently we had a surplus of standard
size facial masks in my office so I went to the hardware store and bought myself which
is now part of the armamentarium for this a die and a die holder and also a tube cutter
or pipe cutter as you see here. Now these may seem like odd pieces of orthodontic equipment
but in fact they are quite useful in adjusting the facial mask. Now the first thing we want
to do is check the size of the facial mask support bar. And as we saw last time this
is about the right size. If it were too long where for example you had a standard size
bow and you had a small patient, this particular type of device here, the pipe cutter, can
be used to actually cut the pipe itself and then by using the die as we see here this
can be used to add new threads on the end. Now I see here that there is a new part of
appliance that I have not seen before and this is, in fact, looks like there’s a new
screw on here or a new bolt. Is that right? Father: Right. That’s the only problem we’ve
had with the appliance. We’ve lost the bolt off of it a couple of times.
Dr. McNamara: Okay. So what you suggested off camera is make sure that this gets tightened
on very tightly when the patient is in the office so that this problem doesn’t happen
again, right? Father: Right.
Dr. McNamara: Okay, now we can take off the lower pad. Now we can use the die, not in
the way it is usually used, because the center part is where the rethreading device is found
but there are also three other holes on here. And what we can do is take one of these holes
with the facial mask in through this area and by using this large fulcrum region we
can place an additional bend in the lower part of the appliance. So this used to be
straight and now it has more of a gentle bend to it. Okay, now I’ve tightened this bolt
down securely. Now would you put it back on? Very good. Now we’re not seeing the plastic
part digging in under the lip and I think this will be much more comfortable for her
to wear. Now the second part of this whole thing as far as a major adjustment has to
do with the crossbow. I’ve had a number of individuals comment upon the fact that these
areas here on the ends are very sharp and as recently as a couple of days ago through
one of the parents they relayed a message from the teacher to find out whether we could
put something over the ends of the crossbow. Now also one other problem with these little
depressions in the wire being where they are is the fact that when the elastics are attached
that they tend to come into the corner of the mouth. So in order to solve these two
problems I’m going to show you a small adjustment that can be made. The part of the crossbow
that we’re going to adjust is this ‘S’ area sort of in here and the main goal is going
to be continue to curve this around so this part is not so sharp and also so that the
patient will be able to wear the elastics a little bit closer to the midline. Now most
orthodontic pliers are really not strong enough to do this. About the only ones that I’ve
really found are the hollow chop pliers. These hollow chop pliers can be used quite successfully
not only for adjusting for example, a transpalatal arch or at least the formation of a transpalatal
arch but they also can be used to recontour the ends of the crossbow. Okay, now we’re
taking the hollow chop pliers, putting it in here and then with a great deal of strength
and whatever, curving it around like so. So you’ll notice there’s been quite a change
in the configuration from the ‘S’ shape and the curved shape here to more of a hooked
shape on the other side. Now we’ve completed the bending of the crossbow part of the appliance
using another pair of pliers, not of the orthodontic variety, supplied to us by one of the television
technicians who felt that this is an easier way to do it and in fact that is the case.
You really need to have a plier of this size in order to make this type of adjustment. Now we’ve put the facial mask back together.
Now can you put it back on for me please? Does that feel different? Stacey: Right here it does. Dr. McNamara: Does that feel better? Feels
different right? (chuckles) Okay? That feel okay? No, it doesn’t feel okay. Alright. What’s
the problem? Stacey: I liked them more under here. Dr. McNamara: You liked them more under here.
(Father laughs) Okay, we can fix that for you. Never fails. Anyway this is basically
the design that we’re looking for. This thing’s now not protruding outward. And there’s much
less of a problem with the corner of the mouth being affected by the appliance. I want to
thank you both for coming today and I think this again will be very helpful in teaching
other people how to use the facial mask. We’ve gone about three or four months now and I’m
very gratified with the results and we’ll try to look at her again in the future to
see how the overall treatment came out. Thank you very much. Thank you Stacey. You have been listening to a presentation
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